**3. Explanations for Capgras syndrome**

Since initial reports of CS involved patients with psychiatric illness, their close relations, and how they interacted with each other, early explanations of the delusion were predominately psychodynamic interpretations. There are several psychodynamic approaches. Consequently, these explanations included suggestions that CS might develop out of Oedipal issues in women as a defence against hostility or incestuous, guilty desires, or out of hidden homosexuality in men. Later attempts to account for CS resulted in hypotheses of anxiety-induced regression of cognitive and emotional functioning, pathological splitting of internalized object representations, insufficiently repressed conflicting or ambivalent feelings toward the implicated person, and the projection of negative emotions that come to light from these conflicting feelings [17]. In the psychodynamic theory, it is supposed that the delusion is a way in which the patient copes with the ambivalent emotions that he feels toward the close family member who is duplicated [15]. There are several explanations brought about by psychodynamic approaches of misidentification syndromes. Premorbid psychopathology, motivation, and loss of ego functions may be important in determining which vulnerable patients develop CS [6].

Capgras delusion can occur due to 'spatial disorientation, anatomic disconnection, memory and executive process impairment, and loss of ego' [4]. While psychodynamic theories consist of ambivalence theory, depersonalization theory, and regression theory, neurocognitive hypotheses focus on right hemispheric dysfunction, face-recognition processing abnormalities, and focal structural cerebral abnormalities [28]. There are two components of the visual recognition of a familiar face, one of which is responsible for conscious recognition of the face and the remembrance of associated semantic information, while the other is responsible for the limbic-mediated emotional arousal including the feeling of familiarity that accompanies the conscious recognition of a known face [9].

### **4. Psychodynamic proposals in Capgras delusion**

Despite the sharp increase in the number of published cases accompanied by various suggestions regarding an organic etiology, to accurately explain the delusion, it is necessary to embrace the psychodynamic as well as the organic. Even if a specific neuropsychological lesion is found in the end, the psychodynamics of the individual will still be pertinent and remain substantial [29]. An association between CS and depersonalization has been thought to exist onward the time when the disorder was first described. Some authors put forward that depersonalization may be the basis of the disorder which may develop in some individuals. CS can be evaluated as a disorder of ego function which permeates the entire personality [29]. Some authors postulated that cerebral dysfunction leads to feelings of derealization and depersonalization which in turn may develop into Capgras' syndrome in the presence of paranoid ideation [29].

The psychodynamic conception of the Capgras phenomenon is basically a lovehate conflict that is resolved by reflecting ambivalent feelings onto a fictitious double [29]. On the one hand, there are a long-standing love and on the other hand a visible hatred. In those cases when it occurs, it is very substantial that before the onset of the delusion of doubles, the patient shows an increased love and sexual desire toward the object. This overreaction results from a desire for reassurance regarding the love of the object and fear of losing it simultaneously. Theories suggested that CS could arise out of an Electra complex and incest desires, Oedipal problems, and latent homosexuality. Personality disintegration coupled with an evolutionary regression to more primitive modes of cognitive and emotional functioning; division of internalized object representations; ambivalent feelings toward a familiar other that are not sufficiently suppressed; and the feelings of anxiety, guilt, and anger resulting from this struggle are reflected onto imagined imposter [20]. Instead of approving these demands, the object becomes even more repulsed and is unable to cover up these feelings that clearly aggravate the situation, and a vicious circle is established [29].

**123**

anterior cortex of the second deficit [9, 30, 32, 36].

*What is Capgras Syndrome? Diagnosis and Treatment Approach*

**5. Face-recognition system in Capgras delusion**

Usually, we do not strive for facial recognition. The ability to identify people who we met before is a headstone of our social interactions. Face recognition is a multistage process ending with the identification of a person. Prosopagnosia is defined as loss of familiarity to previously known faces and the inability to learn to recognize new faces. Although these patients fail to recognize faces, they are still able to show affective responses to these faces [30, 31]. Several studies have suggested that CS represents a 'mirror image' of prosopagnosia, thus suggesting different neural circuits for facial processing: a cognitive circuit (impaired in prosopagnosia) and an affective circuit (impaired in CS). In the affective circuit, the ventral route from the visual centers to the temporal lobes may be protected, also active in conscious face recognition; however, the dorsal visual track that gives the face its emotional significance is damaged. A brief disruption of the ventral visual pathway leads to prosopagnosia, whereas damage to the dorsal visual areas leads to an impaired sense of familiarity for known faces, as in CS [9, 17, 30, 32]. While the ability to identify that person is intact, patient with CS probably has a brain lesion that interferes with the patient's ability to sense a familiarity toward the significant other [15]. It has been suggested that the impairment seen in the Capgras delusion was linked to a disruption of pathways connecting face-sensitive regions to limbic cortex, which is involved in the accompanying emotional response [30]. Perhaps arising from the conflicting experience of recognizing a known face without any accompanying affective reaction, the patient can understand that the absence of this emotional arousal is to establish the belief that the person he is looking at is an imposter [9, 33]. In another connectivity study, posterior coupled with anterior right hemisphere dysfunction may have involved in the emergence of Capgras delusion [34]. Also, it has been suggested that CS results from the disconnection of the face processing regions in the inferior temporal lobe from structures in the limbic system, especially the amygdala, which is very important in assigning emotional value to familiar faces [34]. Common to the CS is a fixed false belief but infrequently transient [35]. However, anatomical disconnection models fail to efficiently consider the transient nature of the misidentification episodes [34]. Therefore, it has been suggested that CS may be associated with the 'kindling of subcortical structures'. Kindling refers to repeated subthreshold stimuli which may result in psychomotor outbursts or overt seizure activity [34]. Autonomic responses and eye movements are involved in face perception which may cause the patient believe that the person has been replaced by an imposter. Studies on patient with CS like other psychiatric disorders have shown abnormal scan paths to facial stimuli or abnormal skin conductance response (SCR) in face processing tasks [30, 33]. The absence of identity recognition, accompanied by a lack of SCR, stimulates the patient to explore unfamiliar faces, and identity recognition of familiar faces leads to a more detailed exploration in the eye region, and it results in gaze avoidance of the eye region [33]. Vision is important in accessing reserved knowledge in the etiology of CS. However, surprisingly CS has also been reported in a number of blind patients which suggests that it cannot have an exclusively visual basis [34]. Some theories assume that two deficits are necessary for delusions to occur in the case of Capgras delusion like other DMSs [32, 36]. This is also called 'two-hit' process [20]. The first one, the brain's ability to attach emotional emphasis, may be the lack of autonomic arousal which leads to the abductive inference that the person is an imposter [30]. The other deficit is an impaired ability to reassess beliefs [the global consistency-checking mechanism] which prevents the rejection of the bizarre belief. The second deficit leads to the persistence of that abnormal perception as a delusion resistant to reasoning, also related to the right

*DOI: http://dx.doi.org/10.5772/intechopen.91153*

*Anxiety Disorders - The New Achievements*

that CS might develop out of Oedipal issues in women as a defence against hostility or incestuous, guilty desires, or out of hidden homosexuality in men. Later attempts to account for CS resulted in hypotheses of anxiety-induced regression of cognitive and emotional functioning, pathological splitting of internalized object representations, insufficiently repressed conflicting or ambivalent feelings toward the implicated person, and the projection of negative emotions that come to light from these conflicting feelings [17]. In the psychodynamic theory, it is supposed that the delusion is a way in which the patient copes with the ambivalent emotions that he feels toward the close family member who is duplicated [15]. There are several explanations brought about by psychodynamic approaches of misidentification syndromes. Premorbid psychopathology, motivation, and loss of ego functions may

be important in determining which vulnerable patients develop CS [6].

accompanies the conscious recognition of a known face [9].

**4. Psychodynamic proposals in Capgras delusion**

presence of paranoid ideation [29].

Capgras delusion can occur due to 'spatial disorientation, anatomic disconnection, memory and executive process impairment, and loss of ego' [4]. While psychodynamic theories consist of ambivalence theory, depersonalization theory, and regression theory, neurocognitive hypotheses focus on right hemispheric dysfunction, face-recognition processing abnormalities, and focal structural cerebral abnormalities [28]. There are two components of the visual recognition of a familiar face, one of which is responsible for conscious recognition of the face and the remembrance of associated semantic information, while the other is responsible for the limbic-mediated emotional arousal including the feeling of familiarity that

Despite the sharp increase in the number of published cases accompanied by various suggestions regarding an organic etiology, to accurately explain the delusion, it is necessary to embrace the psychodynamic as well as the organic. Even if a specific neuropsychological lesion is found in the end, the psychodynamics of the individual will still be pertinent and remain substantial [29]. An association between CS and depersonalization has been thought to exist onward the time when the disorder was first described. Some authors put forward that depersonalization may be the basis of the disorder which may develop in some individuals. CS can be evaluated as a disorder of ego function which permeates the entire personality [29]. Some authors postulated that cerebral dysfunction leads to feelings of derealization and depersonalization which in turn may develop into Capgras' syndrome in the

The psychodynamic conception of the Capgras phenomenon is basically a lovehate conflict that is resolved by reflecting ambivalent feelings onto a fictitious double [29]. On the one hand, there are a long-standing love and on the other hand a visible hatred. In those cases when it occurs, it is very substantial that before the onset of the delusion of doubles, the patient shows an increased love and sexual desire toward the object. This overreaction results from a desire for reassurance regarding the love of the object and fear of losing it simultaneously. Theories suggested that CS could arise out of an Electra complex and incest desires, Oedipal problems, and latent homosexuality. Personality disintegration coupled with an evolutionary regression to more primitive modes of cognitive and emotional functioning; division of internalized object representations; ambivalent feelings toward a familiar other that are not sufficiently suppressed; and the feelings of anxiety, guilt, and anger resulting from this struggle are reflected onto imagined imposter [20]. Instead of approving these demands, the object becomes even more repulsed and is unable to cover up these feelings that clearly aggravate the situation, and a vicious circle is established [29].

**122**
